Differences in strategies for prevention of COVID-19 transmission in hospitals: nationwide survey results from the Republic of Korea.

BACKGROUND: Hospital infection control measures against coronavirus disease 2019 (COVID-19) are often based on expert discretion due to the lack of detailed guidelines. AIM: To survey the current strategies for preventing the transmission of COVID-19 in medical institutions.
METHODS: Thirteen key issues related to the prevention of COVID-19 transmission within medical institutions were selected via discussion among infectious diseases specialists, and related critical questions were obtained following a review of national-level guidelines in government databases. Six hospitals had an open survey between 11th and 25th August 2020 to provide responses to these topics. An online questionnaire developed from these data was sent to infection control teams at 46 hospitals in South Korea between 31st January 2021 and 20th February 2021.
FINDINGS: All 46 hospitals responded to the survey. All operated screening clinics, but 89.1% (41/46) allowed symptomatic patients without COVID-19-associated symptoms to visit general outpatient clinics. Most hospitals (87.2%, 34/39) conducted polymerase chain reaction (PCR) tests for all hospitalized patients. Of 35/46 (76.1%) hospitals with pre-emptive isolation policies for hospitalized patients, 31 (88.6%) released patients from isolation after a single negative PCR test, while most (76.9%, 20/26) allowed shared-room accommodation for patients meeting the national criteria for release from isolation despite positive PCR results with above cycle threshold values (34.6%, 9/26), or after a certain period that satisfied the national criteria (26.9%, 7/26).
CONCLUSION: Individual hospitals in South Korea are currently relying on experience to frame relevant guidelines, and responded differently to some infection control issues on hospital settings during the COVID-19 pandemic.

Introduction

Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that was discovered in December 2019 in Wuhan, China [1]. Subsequently, it spread rapidly worldwide, and the World Health Organization (WHO) declared a global pandemic on March 11, 2020 [2]. COVID-19 outbreaks in medical institutions are important, and can be associated with high mortality rates, especially amongst the elderly [[3], [4], [5], [6]]. Although strict infection control measures to prevent nosocomial COVID-19 are crucial, the development of these may need to be tailored locally, because of the heterogeneity of hospitals and their patient populations [7]. Thus, COVID-19 infection control measures in hospitals often rely on the experience and opinion of in-house experts, and may be benchmarked against other hospitals’ strategies [8].

In the light of these issues, the present study aimed to evaluate the issues of infection control strategies for COVID-19, which were not appropriately dealt with in the guidelines, in the real-world setting in Korean hospitals during the early pandemic.

Methods

Questionnaire design

In the initial phase of questionnaire development, 13 issues related to the prevention of COVID-19 transmission within medical institutions were selected via discussion among four infectious diseases (ID) specialists (BK, ESK, KHS, and HBK) (Supplement I). To extract the critical questions related to these issues that are relevant in an actual hospital setting, governmental database review of the recommendations and guidelines issued by World Health Organization (WHO), Centres for Disease Control and Prevention (CDC), European Centre for Disease Prevention and Control (ECDC), and Korea Disease Control and Prevention Agency (KDCA) between 1st January 2020 and 30th September 2020 was conducted by two researchers (WJ and BK) (Supplement II). In addition, we obtained information about real-world practices related to these issues from six ID specialists working at different hospitals by sending an email with a questionnaire consisting of open questions (Supplement III). Based on a review of the guidelines and information about real-world practices, a questionnaire consisting of 71 questions was developed through discussions among investigators in this study (Supplement IV). After conducting a pilot test by the investigators the developed questionnaire was refined on the SurveyMonkey® platform (Supplementary Figure 1).

Conducting the survey

The survey was conducted over a 21-day period, 31st January to 20th February 2021, targeting the six hospitals where information about real-world practices for controversial topics was gathered and 40 sample hospitals in South Korea that managed COVID-19 patients at the time of the survey. The 40 hospitals were selected based on the hospital type and regional distribution. Hospitals were assessed on bed numbers and whether they had state-designated isolation beds and ID specialists into one of four categories: those with 500 with or without state-designated isolation beds, those with <500 beds, and those without ID specialists. Ten hospitals were selected per category while maintaining uniform distributions across regions as much as possible.

A link to the online-based survey was forwarded via e-mail to physician or nurse members of the infection control teams (ICTs) of each hospital. Hospital ICTs in South Korea are infection control doctors and nurses dedicated to infection control and prevention in their hospital [9]. Given that the main practitioners related to the COVID-19 response vary depending on the hospitals, a person in charge of practical affairs was asked to answer according to the circumstances of each hospital. To encourage participation, reminders were sent on the 5th, 10th, and 15th days. Only one questionnaire was administered per hospital.

Results

Basic information on participating hospitals (Table I)

All 46 invited hospitals responded to the survey. Among them, 13.0% (6/46) were university-affiliated national or public hospitals, 32.6% (15/46) were university-affiliated private hospitals, 37.0% (17/46) were non-university-affiliated national or public hospital, and 17.4% (8/46) were non-university-affiliated private hospital. There were no infectious diseases specialists in 21.7% (10/46) of the participating hospitals.

Screening and selective treatment policies to prevent COVID-19 patients from entering hospitals (Table II)

All 46 hospitals operated screening clinics, which treated patients with respiratory symptoms, fever of unknown cause, and epidemiological association with COVID-19 patients, and accepted persons who wanted to undergo polymerase chain reaction (PCR) tests for COVID-19.

41/46 (89.1%) hospitals allowed patients with symptoms generally unrelated to COVID-19 to visit the general outpatient clinics. 38 (92.7%) of these 41 hospitals used a negative COVID-19 test results within a certain period to determine whether symptomatic patients could enter the general outpatient clinics.

42/46 (91.3%) hospitals implemented measures to prevent the introduction of COVID-19 into the hospital by caregivers/visitors. 38/42 (90.5%) allowed general ward access only to the patients’ essential caregivers, 24/42 (57.1%) regularly monitored fever and respiratory symptoms of caregivers, and 27/42 (64.3%) performed mandatory PCR tests for caregivers.

All medical institutions provided education concerning the use of masks for patients and caregivers, while 35/46 (76.1%) made regular public address announcements guiding patients and caregivers to wear masks. Only 10 (21.7%) hospitals had designated staff to monitor and provide guidance to patients and visitors on mask-wearing. PCR tests were performed even for non-suspected cases of COVID-19 in 39/46 (84.8%) hospitals, and 34 (87.2%) of these 39 hospitals tested all patients requiring hospitalisation. Additional screening and selective treatment policies for patients with suspected COVID-19 are provided in the Supplementary Table I.

Pre-emptive isolation policies for patients admitted with symptoms of possible COVID-19 (Table III)

Pre-emptive isolation of patients with symptoms suggestive of COVID-19 was used in 35/46 (76.1%) of hospitals. The majority (65.7%) of hospitals had a policy of universal isolation of admitted patients. Thirty-one (88.6%) of these 35 hospitals de-isolated patients after the first negative PCR test after hospitalisation, and 3 (8.6%) required two negative swabs. The remaining centre released patients on a case-by-case basis. Additional information on isolation policies for patients with suspected or confirmed COVID-19 is provided in Supplementary Table I.

Management of COVID-19 patients whose PCR results remained positive but whose symptoms improved allowing release from isolation (Table IV)

During the study period, according to national guidelines, COVID-19 patients who were at least 10 days after symptom-onset could be released from isolation if their symptoms were improved and they were afebrile [7]. Twenty-seven (58.7%) of hospitals followed this recommendation. Most (76.9%) hospitals allowed de-isolated patients to occupy shared rooms, but often required addition criteria to be met (e.g. Ct value thresholds)

Procedures and operations for patients with suspected or confirmed COVID-19 (Table V)

Most (76.1%) institutions performed emergency procedures or operations for suspected COVID-19 patients, but 85.3% of hospitals postponed elective procedures or operations on suspected COVID-19 patients until they were de-isolated and 78.8% postponed electaive procedure or surgery on patients with confirmed COVID-19 until they were de-isolated. Some centres required additional criteria to be met, e.g. Ct value thresholds or a time period after release from isolation.

Hospital work-restriction policy for healthcare workers (Table VI)

Healthcare workers who had visited high COVID-19-risk areas, and who were asymptomatic, were excluded from work and PCR-tested if they became symptomatic in 43.2% of hospitals. All hospitals excluded healthcare workers with fever or respiratory symptoms from work and conducted PCR tests. However, only 29/46 (63.0%) hospitals placed restrictions on healthcare workers’ activities outside the hospital. Fourteen (30.4%) of hospitals required staff to have a negative PCR test result before returning to work, and only 12 (26.1%) hospitals allowed healthcare workers to return to work immediately after meeting the national isolation release criteria. Additional data for decision-making system for COVID-19 related issues is provided in the Supplementary Table III.

Personal protective equipment for healthcare workers providing care for patients with COVID-19 (VII)

The majority of hospitals provided ‘coveralls with powered air-purifying respirator (PAPR)’ and ‘coveralls with N95/KF94 mask’ for the treatment of patients with COVID-19. While 43.6% of hospitals provided ‘coveralls with PAPR’ for the treatment of asymptomatic or mild to moderate patients, 86.5% and 92.3% of hospitals provided this for the treatment of severe patients and patients who need aerosol-producing procedures, respectively. The proportion of hospitals that provided ‘coveralls with N95/KF94 mask’ for the management of patients suspected of COVID-19 was 39.5%, which was lower than that which provided ‘N95/KF94 mask, disposable gown, gloves, and goggles/face shields’ (57.9%). Additional information about PPE for healthcare workers is provided in Supplementary Table II.

Discussion

This study investigated the measures taken by medical institutions to prevent the spread of COVID-19 in South Korea. We were this able to identify real-world strategies, especially in areas where no detailed guidelines had been established.

All hospitals operated screening clinics, and approximately 90% allowed patients with symptoms not considered to be associated with COVID-19 to enter their general outpatient clinics. Because screening clinics have minimal facilities and a workforce that can only provide a minimal examination [10], most hospitals managed patients with fever and respiratory symptoms, but unlikely to have COVID-19, in general outpatient clinics (where careful evaluation and management could be provided). Unfortunately, there were no clear criteria for the entry of symptomatic patients into the general outpatient clinics, which could lead to confusion among frontline medical professionals [7]. At the time of writing, unlike when the study was conducted, unrestricted general outpatient clinic entry has been allowed in almost all South Korean hospitals since the emergence of the omicron variant. As countermeasures to the surge of the highly transmissible but less serious omicron variant South Korean hospitals were encouraged to perform COVID-19 diagnostic testing, and to participate in the management of low-risk COVID-19 patients at their outpatient clinics, since 3rd February 2022 [11].

Because of concerns regarding COVID-19 transmission by asymptomatic patients, CDC recommended universal PCR testing of hospitalised patients, even those who are asymptomatic [12]. Nevertheless, approximately 15% of the hospitals in this study did not test asymptomatic patients. According to the Infectious Diseases Society of America (IDSA), screening asymptomatic patients is expected to be effective when the prevalence is at least 2%, taking account of the consequences of missed diagnoses, and the accuracy of PCR tests [13]. Although they may be less accurate, rapid antigen tests may be considered as an alternative screening option, especially where access to PCR testing is constrained [14].

Three-quarters of the hospitals in the present study implemented pre-emptive isolation for suspected COVID-19 patients, and most required at least one negative COVID-19 PCR test for deisolation. WHO and CDC recommend different criteria for deisolation; the WHO criteria relate to symptom disappearance, whilst CDC required a single negative PCR test [7]. In a single-centre study in South Korea, 350 symptomatic patients with epidemiological associations with COVID-19 patients pre-emptively isolated and none were confirmed to have COVID-19 [15]. This might suggest that universal pre-emptive isolation of symptomatic inpatients with no clear epidemiological association with COVID-19 may not be required. Where PCR is performed it needs to be borne in mind that a single negative test may not provide assurance that a patient does not have COVID-19 since the mean incubation period for COVID-19 is 5.2 days; a single negative PCR test result should be considered, especially for patients with a recent history of contact with COVID-19 [[16], [17], [18], [19]].

Although the probability of infectious SARS-CoV-2 is usually very low after 10 days from symptom-onset, severely ill or immunocompromised patients can remain infectious for longer [18, [20], [21], [22], [23]], and the possibility of continuing infectivity of hospitalised patients, especially those undergoing aerosol-generating procedures, is hotly debated [22, [24], [25], [26]]. This explains why only 19% of our hospitals de-isolated COVID-19 patients into shared rooms regardless of the PCR test result. Despite concerns about transmission of COVID-19 in hospitals, even after 10 days of isolation, many countries including South Korea advise that isolation can be discontinued after 10 days. To do otherwise would be costly in terms of healthcare resources, and of questionable clinical effectiveness [27].

We found that most hospitals provided coveralls as PPE for healthcare workers managing confirmed COVID-19 cases. A Korean study showed that even though most healthcare workers knew that the Korea Disease Control and Prevention Agency (KDCA) guidelines allowed healthcare workers to choose either coveralls or long-sleeved gowns, many healthcare workers did not use long-sleeved gowns [28]. This might be attributable to confusion among healthcare workers about COVID-19 transmission due to the initial KDCA recommendation about PPE; at the beginning of the pandemic, KDCA recommended using coveralls during managing COVID-19 patients [29]. A recent study found that coverall contamination rarely occurred even while managing severe COVID-19 patients at the early stage of the illness, and in an April 2021 guideline update coveralls are no longer recommended [30, 31].

Since healthcare workers can also spread COVID-19 in hospitals, many have applied stricter return-to-work criteria than are defined in national guidelines. We found that over one-third of hospitals required a negative PCR test result from asymptomatic healthcare workers who visited high-risk areas. However, such stringency can result in a lack of a sufficient workforce [32]. Internationally, return-to-work criteria for healthcare workers are now being eased. For example, CDC updated its criteria in January 2022 so that asymptomatic healthcare workers who have had SARS-CoV-2 infection over the previous 90 days do not require work restrictions following further exposure [33].

This study has limitations. First, it was conducted in February 2021, and will not necessarily reflect current practice. Second, selection bias might arise from most of the surveyed hospitals having ID specialists, and being public hospitals mainly selected; selection of participants was not randomized. Third, the survey was performed only in South Korea, and may not be representative of other countries [34, 35]. Nevertheless, the findings remain important since they highlight the importance of appropriate guidelines and indicate key topics relevant to real hospital settings for further research based on the results of this study.

Conclusions

Individual hospitals in South Korea were relying on experience to frame relevant guidelines and responded differently to some infection control issues in hospital settings during the COVID-19 pandemic.

Funding statement

This work was supported under the framework of the international cooperation program managed by the National Research Foundation of Korea (2020K2A9A1A0109507911). The funders had no role in the study design, data collection and analysis, preparation of the manuscript, or the decision to publish.

Ethics approval and consent to participate

The study protocol was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (B-2101/660-303). Online written informed consent was obtained from the participants.

Declaration of Competing Interest

None to declare.

Table 1

Basic information of medical institutions participating in the survey

Hospital characteristics	No. (%)(n = 46)
Type of hospital
University-affiliated hospital: national or public	6 (13.0)
University-affiliated hospital: private	15 (32.6)
Non-university-affiliated hospital: national or public	17 (37.0)
Non-university-affiliated hospital: private	8 (17.4)
Number of hospital beds
Less than 300	10 (21.7)
300-599	15 (32.6)
600-899	11 (23.9)
900-1,199	4 (8.7)
More than 1,200	6 (13.0)
No infectious diseases specialists	10 (21.7)

Table 2

Screening and selective treatment policy to prevent COVID-19 patients from entering hospitals

	No. (%)(n = 46, unless otherwise stated)
Existence of screening clinic for COVID-19	46 (100)
The criteria of patients treated at the screening clinica
Fever of unknown cause	45 (97.8)
Respiratory symptoms	46 (100)
Epidemiological association with COVID-19 patients	43 (93.5)
Family members had fever, respiratory symptoms, or epidemiological association with COVID-19 patients	35 (76.1)
Test for COVID-19 voluntarily	39 (84.8)
Entry into general outpatient clinics was allowed for patients with fever or respiratory symptoms likely not associated with COVID-19a	41 (89.1)
No epidemiological association with COVID-19 patients	11/41 (26.8)
Healthcare workers at the screening clinic determines that the possibility of COVID-19 is minimal	24/41 (58.5)
The patients were negative for COVID-19 testing within a certain period (e.g., two to three days)	38/41 (92.7)
Scheduled follow-up for diseases presenting fever or respiratory disease	26/41 (63.4)
Existence of measures to prevent the influx of COVID-19 into the hospital caused by caregivers and family/acquaintancesa	42 (91.3)
Restrictions on access to general wards by visitors other than the patient's essential caregivers	38/42 (90.5)
Total restrictions on visits to general wards	21/42 (50.0)
Total restrictions on visits to intensive care units and special wards	28/42 (66.7)
Regular monitoring of fever and respiratory symptoms of the caregivers	24/42 (57.1)
Mandatory PCR test for caregivers	27/42 (64.3)
Existence of system to pre-screen scheduled patients to prevent the influx of suspected cases of COVID-19a,b	35 (76.1)
Texts are sent to suspected cases of COVID-19 advising them to not visit the general outpatient area	28/35 (80.0)
Self-examinations for suspected cases of COVID-19 are conducted through the internet or mobile before visiting the hospital	21/35 (60.0)
Phone call interviews are conducted on suspected cases of COVID-19	3/35 (8.6)
Management and education concerning wearing masks for patients and caregivers in the hospitala	46 (100)
Education on wearing masks is provided to patients and caregivers when hospitalized	33 (71.7)
Banners and postings on wearing masks thoroughly and properly are placed throughout the institution	41 (89.1)
Regular public address announcements on the need for patients and guardians to wear masks	35 (76.1)
Designated staff monitor patients and guardians and provide guidance on wearing masks in the hospital	10 (21.7)
Performing PCR tests for non-suspected cases of COVID-19a	39 (84.8)
The subject of testing
Patients requiring general anaesthesia	19/39 (48.7)
All patients requiring hospitalization	34/39 (87.2)
Patients requiring hospitalization in a closed psychiatric ward	9/39 (23.1)
Patients who came from a different institution or a nursing home	16/39 (41.0)
Patients requiring hospitalization in the intensive care unit	9/39 (23.1)

This question requested the respondent to select multiple items.

Suspected cases of COVID-19 include fever, respiratory symptoms, and epidemiological associations with COVID-19 patients.

Table 3

Isolation practices for patients with symptoms of possible COVID-19, but without a confirmed diagnosis

	No. (%)(n = 35)
Healthcare workers who determine pre-emptive isolation
Pre-emptive isolation for all patients or patients who meet specific conditions	7 (20.0)
The doctor who directly treated the patient	26 (74.3)
Healthcare workers belonging to specific departmentsb	22 (62.9)
Type of isolation rooms
Single isolation room	31 (88.6)
Cohort isolation room	6 (17.1)
Partly operated as cohort isolation room, and other single rooms	8 (22.9)
Criteria for removing the patients from pre-emptive isolation
COVID-19 PCR test confirmed negative once	31 (88.6)
COVID-19 PCR test confirmed negative twice	3 (8.6)
Determined on a case-by-case basis	1 (2.9)
Range of patients isolated before PCR results were confirmed
All patients admitted into the hospital	23 (65.7)
Existence of suspected symptoms of COVID-19	12 (34.3)
Existence of results of imaging tests that are suspected to be pneumonia	12 (34.3)
Existence of epidemiological association with a COVID-19 patient	12 (34.3)
Patients being admitted to high-risk wardsb	3 (8.6)
Patients came from a nursing home or were transferred from a different institution	3 (8.6)

Note: Only hospitals with policies on pre-emptive isolation were included.

a Infectious diseases, pulmonology, &/or infection prevention & control practitioners.

Intensive care units &/or haematopoietic stem cell transplant wards.

Table 4

Policies for patients with COVID-19 whose PCR results remained positive but whose symptoms improved allowing release from isolation

	No. (%)(n = 27, unless otherwise stated)
Personal protective equipment for the treatment of the patientsa
Coveralls with PAPR	0 (0)
Coveralls with N95/KF94 mask	0 (0)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover + shoe covers	0 (0)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover	2 (7.4)
N95/KF94 mask + disposable gown + gloves + goggles/face shields	3 (11.1)
N95/KF94 mask + disposable gown + gloves	4 (14.8)
N95/KF94 mask + gloves	4 (14.8)
N95/KF94 mask	17 (63.0)
Surgical mask	11 (40.7)
Allocation of hospital rooma,b
Shared room in a general ward	20/26 (76.9)
Regardless of the PCR test results (Ct value) or the time of release from isolation	5/26 (19.2)
If PCR test results (Ct value) meet certain criteria	9/26 (34.6)
After a certain period from the time of release from isolation, regardless of the PCR test results (Ct value)	7/26 (26.9)
Single room for isolation, without negative pressure	4/26 (15.4)
Regardless of the PCR test results (Ct value) or the time of release from isolation	1/26 (3.8)
If PCR test results (Ct value) meet certain criteria	3/26 (11.5)
After a certain period from the time of release from isolation, regardless of the PCR test results (Ct value)	1/26 (3.8)
Single room for isolation with negative pressure	2/26 (7.7)
Cohort room for isolation with negative pressure	0/26 (0)

This question requested the respondent to select multiple items.

One hospital wrote a non-categorical answer for the question, and the hospital decided after consulting with the infectious disease specialist.

Table 5

Procedures & operations on patients with suspected or confirmed COVID-19

	No. (%)(n = 46, unless otherwise stated)
The decision-making process for operations or procedures on patients suspected of COVID-19 in an emergency situationa
No operations or procedures are performed for patients suspected of COVID-19	11 (23.9)
Even in an emergency, all surgeries and procedures are prohibited until a negative PCR result is confirmed	8 (17.4)
Decisions are made by the person in charge of the specific departmentb	16 (34.8)
Decisions are made by the doctor who is in charge of the patient	12 (26.1)
Decisions are made through the discussion of a consultative committee in the hospital	5 (10.9)
Operations and procedures are performed based on the patient confirmed with COVID-19	21 (45.7)
Performing emergency procedures or operations on patients suspected of COVID-19	35 (76.1)
Elective procedures or operations on patients suspected of COVID-19 requiring preemptive isolationc
All procedures or operations are postponed until the patient is released from preemptive isolation	29/34 (85.3)
Procedures or operations are performed without delay, wearing personal protective equipment for COVID-19	5/34 (14.7)
Procedures or operations are performed without delay, without wearing personal protective equipment for COVID-19	0/34 (0)
Elective procedures or operations on patients confirmed with COVID-19d
All procedures or operations are postponed until the patient is released from isolation	26/33 (78.8)
Procedures or operations are performed without delay, wearing personal protective equipment for COVID-19	7/33 (21.2)
Elective procedures or operations on patients with COVID-19 whose PCR results are consistently positive but whose symptoms have improved and are released from isolatione
All procedures or operations are postponed until a negative PCR result is confirmed	3/25 (12.0)
Procedures or operations are performed without delay, wearing personal protective equipment for COVID-19	1/25 (4.0)
Procedures or operations are performed without delay, without wearing personal protective equipment for COVID-19	5/25 (20.0)
Procedures or operations are performed if PCR test results (Ct value) meet certain criteria	10/25 (40.0)
Procedures or operations are performed after a certain period from the time of release from isolation, regardless of the PCR test results (Ct value)	6/25 (24.0)

This question requested the respondent to select multiple items.

It includes infectious diseases, pulmonology, and the infection control and prevention office.

11 hospitals that did not have a preemptive isolation policy for patients suspected of COVID-19 and 1 hospital that did not perform elective procedures or operations were excluded.

7 hospitals that did not have an isolation policy for patients confirmed with COVID-19 and 6 hospitals that did not perform elective procedures or operations were excluded.

19 hospitals that did not have a policy for patients with COVID-19 whose PCR results are consistently positive but whose symptoms have improved and are released from isolation and 2 hospitals that did not perform elective procedures or operations were excluded.

Table 6

Hospital work restriction policies for healthcare workers

	No. (%)(n = 46, unless otherwise stated)
Those who have visited high-risk areas of COVID-19, without fever or respiratory symptomsa
Work is restricted for a certain period without PCR test	5/44 (11.4)
Work is restricted for a certain period, performing PCR test	3/44 (6.8)
Work is restricted until negative PCR results are confirmed	15/44 (34.1)
Monitored without PCR test. If they become symptomatic, a PCR test is conducted, and they are restricted from work	19/44 (43.2)
Those who have fever or respiratory symptoms
Work is restricted for a certain period without PCR test	0 (0)
Work is restricted for a certain period, performing PCR test	0 (0)
PCR tests are performed, and work is restricted until negative results are confirmed	46 (100)
Existence of restrictions on certain activities outside the hospitalb	29 (63.0)
Prohibition on attending offline conferences or symposiums	19/29 (65.5)
Prohibition on eating out or attending get-togethers	20/29 (69.0)
Prohibition on travelling overseas	26/29 (89.7)
Prohibition on using multi-use facilities	17/29 (58.6)
Prohibition on using public transport	0/29 (0)
Prohibition on visiting other regions	3/29 (10.3)
The conditions for returning to work among COVID-19 infected employees after national isolation release criteria has been met
Immediately after meeting national isolation release criteria	12 (26.1)
After a certain period following release from isolation, regardless of PCR test results	9 (19.6)
The PCR test results (Ct value) meet certain criteria	11 (23.9)
After confirming negative PCR results	14 (30.4)

Note: Values are presented as number (%).

Abbreviations: PCR, polymerase chain reaction; COVID-19, coronavirus disease 2019; Ct, cycle threshold.

Two hospitals that did not have a work restriction policy for healthcare workers those who had visited high-risk areas were excluded. Two hospitals wrote non-categorical answers for the question. One hospital monitored the employees after performing PCR tests without work restriction, and another hospital decided in the infection control office.

This question requested the respondent to select multiple items.

Table 7

Personal protective equipment for healthcare workers providing care for patients with COVID-19

	No. (%)(n = 46, unless otherwise stated)
Personal protective equipment for the treatment of patients confirmed with COVID-19: asymptomatic or mild to moderate symptomsa,b
Coveralls with PAPR	17/39 (43.6)
Coveralls with N95/KF94 mask	37/39 (94.9)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover + shoe covers	5/39 (12.8)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover	5/39 (12.8)
N95/KF94 mask + disposable gown + gloves + goggles/face shields	3/39 (7.7)
N95/KF94 mask + disposable gown + gloves	1/39 (2.6)
N95/KF94 mask + gloves	0/39 (0)
N95/KF94 mask	0/39 (0)
Surgical mask	0/39 (0)
Personal protective equipment for the treatment of patients confirmed with COVID-19: severe symptomsa,c
Coveralls with PAPR	32/37 (86.5)
Coveralls with N95/KF94 mask	33/37 (89.2)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover + shoe covers	4/37 (10.8)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover	3/37 (8.1)
N95/KF94 mask + disposable gown + gloves + goggles/face shields	2/37 (5.4)
N95/KF94 mask + disposable gown + gloves	0/37 (0)
N95/KF94 mask + gloves	0/37 (0)
N95/KF94 mask	0/37 (0)
Surgical mask	0/37 (0)
Personal protective equipment for the treatment of patients confirmed with COVID-19: aerosol-producing proceduresa,b
Coveralls with PAPR	36/39 (92.3)
Coveralls with N95/KF94 mask	22/39 (56.4)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover + shoe covers	2/39 (5.1)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover	2/39 (5.1)
N95/KF94 mask + disposable gown + gloves + goggles/face shields	3/39 (7.7)
N95/KF94 mask + disposable gown + gloves	0/39 (0)
N95/KF94 mask + gloves	0/39 (0)
N95/KF94 mask	0/39 (0)
Surgical mask	0/39 (0)
Personal protective equipment for the treatment of patients suspected of COVID-19a,d
Coveralls with PAPR	2/38 (5.3)
Coveralls with N95/KF94 mask	15/38 (39.5)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover + shoe covers	7/38 (18.4)
N95/KF94 mask + disposable gown + gloves + goggles/face shields + hair cover	22/38 (57.9)
N95/KF94 mask + disposable gown + gloves + goggles/face shields	13/38 (34.2)
N95/KF94 mask + disposable gown + gloves	1/38 (2.6)
N95/KF94 mask + gloves	0/38 (0)
N95/KF94 mask	0/38 (0)
Surgical mask	0/38 (0)

This question requested the respondent to select multiple items.

7 hospitals that did not have an isolation policy for patients confirmed or suspected with COVID-19 were excluded.

7 hospitals that did not have an isolation policy for patients confirmed with COVID-19 and 2 hospitals that did not perform aerosol-producing procedures were excluded.

7 hospitals that did not have an isolation policy for patients suspected with COVID-19 and one hospital that did not operate a screening clinic were excluded.